Abstract:Knee osteotomies have been established for more than a century as an effective treatment for degenerative and post-traumatic deformities of the lower limb. The aim of this narrative review is to present the current state of knee osteotomies and to outline the relevance of correction in the coronal, sagittal, and axial planes, as based on current evidence and clinical examples.Technical advances, such as digital preoperative planning, biplanar osteotomy techniques, and modern locking plate fixation have significantly reduced complication rates and improved overall clinical outcomes. Open-wedge high tibial osteotomy remains the standard procedure for tibial-based varus deformities and yields excellent results when appropriately indicated. For femoral-based varus or valgus malalignment, biplanar distal femoral osteotomy has become the preferred technique. The use of a hinge wire led to a reduced risk of intraoperative hinge fractures. Double osteotomies are particularly useful in combined deformities of the femur and tibia, and allow preservation of the orientation of the physiological joint line. Several studies have reported excellent functional outcomes with this approach. Corrections in the sagittal and axial planes are gaining increasing importance, especially in cases of patellofemoral pathology, increased tibial slope, or post-traumatic rotational deformities. Overall, knee osteotomies are a reliable and effective method for managing complex deformities. When properly indicated, they can delay or even avoid the need for knee arthroplasty, offering a durable joint-preserving treatment option.
Background:Osteoid osteoma is a benign but painful bone tumour that typically occurs in the long bones of young adults. Intra-articular localisation in the trochlea tali is rare and may significantly delay diagnosis. Case report:We report the case of a 41-year-old patient presenting with persistent, predominantly nocturnal pain of the right ankle joint, despite previous arthroscopic treatment of an osteochondral lesion. Initial conventional imaging was unremarkable. The diagnosis of an osteoid osteoma of the trochlea tali was established only after targeted re-evaluation using contrast-enhanced magnetic resonance imaging (MRI) and high-resolution computed tomography (CT). A diagnostic trial with acetylsalicylic acid resulted in marked symptom relief and further supported the suspected diagnosis, consistent with the known NSAID sensitivity of osteoid osteoma. Definitive treatment was performed using CT-guided radiofrequency ablation (RFA). The patient was completely symptom-free four weeks after the intervention. Conclusion:This case highlights the diagnostic challenges of intra-articular osteoid osteomas in atypical locations. Careful clinical assessment, appropriate imaging, and interdisciplinary collaboration are essential for timely diagnosis and successful treatment.
Introduction:The use of minimally invasive techniques for total hip arthroplasty (THA) in at-risk patients is still debated. The purpose of this prospective study was to determine the clinical and radiographic results of obese patients undergoing THA compared with those of normal-weight patients. Material and methods: A total of 476 patients of the 516 patients who underwent THA via the minimally invasive SuperPath approach between January 2016 and December 2019 attended the 1-year follow-up. Based on the WHO criteria for obesity, 22 patients were underweight, 147 were normal-weight, 186 were overweight, 73 were grade 1 obese, 25 grade 2 obese and 22 grade 3 obese. The clinical outcomes were evaluated using the Forgotten Joint Score (FJS). Radiographic analysis was performed with the digital software tool mediCad (HECTEC, Landshut, Germany). Results:The mean operating time was significantly longer at 81 min (55-96) in grade-3 obese patients than in underweight patients with 67 min (52-79; p = 0.01), normal-weight patients with 71 min (34-105; p = 0.04) and overweight patients with 70 min (50-100; p = 0.04). There were no significant differences between the six groups with regard to the hemoglobin drop between the preoperative state and the 2nd and 4th postoperative day. The mean "time to stairs" did not differ significantly (p > 0.05) between the six study groups. Normal-weight patients had a significantly lower inclination with 38.6° compared to overweight patients (40.3°; p = 0.04) and patients with grade 1 obesity (41.2°; p = 0.02). The inclination angles of patients with grade 2 (42.5°) and grade 3 obesity (42.6°) were highly significantly higher (p < 0.01) than in normal-weight patients. The mean anteversion angle of underweight patients (16.2°) was significantly lower than in normal-weight patients (17.6°; p = 0.03), overweight patients (17.8°, p = 0.02) and patients with grade 2 obesity (17.4°; p = 0.04). The mean anteversion angles in patients with grade 1 (18.3°) and grade 3 (18.1°) obesity were highly significantly higher than in underweight patients. The mean FJS-12 did not differ significantly (p > 0.05) between the six cohorts. Five patients had complications in the early postoperative period, three of whom were normal-weight. Discussion:The current study shows that obese patients undergoing THA via the minimally invasive SuperPath approach have equivalent complication rates and clinical and radiographic outcomes at the 1-year follow up compared with normal-weight and overweight patients.
Background:C-reactive protein (CRP) is an established component of perioperative diagnostics in primary hip and knee arthroplasty; however, its clinical value and the validity of commonly used thresholds remain controversial. The aim of this study was to assess the pre- and postoperative handling of CRP at certified German arthroplasty centres (EPZ) and to critically appraise its clinical relevance. Methods:A 12-item internet-based questionnaire on the perioperative use of CRP was mailed to all 659 centres certified in April 2024; 134 centres participated anonymously. In 2023, these centres had performed a total of 91793 primary hip and knee arthroplasties. Results:Preoperatively, 130 of 134 centres (97.0%) determined CRP routinely. The thresholds applied varied considerably (< 5 mg/l: 48 centres; < 10 mg/l: 69; > 10 mg/l: 11). When the threshold was exceeded, 78 centres primarily referred patients for external evaluation, whereas 39 performed the work-up themselves. Most centres considered the probability of identifying a treatable focus to be low; when no focus was found, 67 of 130 centres proceeded with surgery nonetheless. Postoperatively, 126 centres determined CRP, but only 93 considered this necessary. The timing varied markedly, with 40.5% measuring as early as the first postoperative day. Additional inflammatory parameters were rarely obtained. Only seven centres based the indication for revision primarily on the CRP value. Conclusion:CRP is used frequently but heterogeneously in perioperative diagnostics. Given its limited specificity, particularly for mildly elevated values, and the well-known physiological postoperative increase, routine postoperative CRP measurement appears dispensable in uncomplicated cases. A standardised checklist and a stronger clinical focus could render diagnostics more efficient.
Background:Intertrochanteric rotational osteotomy (ITO) is a joint-preserving option in selected patients with symptomatic femoral torsional abnormalities. Functional results beyond 15 years are scarce. This study describes the long-term functional and patient-reported status after isolated ITO; it is not designed to demonstrate efficacy or superiority. Methods:A monocentric retrospective cohort of 60 patients was evaluated 16.6 years after isolated rotational or derotational osteotomy. Functional outcomes were assessed using HHS, WOMAC, EQ-5D-5L, and clinical examination. Exploratory multivariable regression was used to assess potential associations with functional and patient-reported outcome parameters. Results:More than 75% of patients achieved good to excellent outcomes (mean HHS 85 ± 15). Mean WOMAC score was 11 ± 13, and mean EQ-5D-5L index was 0.843 ± 0.189. No conversion to total hip arthroplasty was observed during follow-up. Female sex was associated with higher WOMAC scores and lower EQ-5D-5L values. Conclusion:In this retrospective single-arm cohort, isolated intertrochanteric rotational or derotational osteotomy was accompanied by stable functional and patient-reported values over a mean of 16,6 years, with no conversion to total hip arthroplasty during follow-up. Sex and the documented rotational correction angle were associated with selected patient-reported outcomes. Because of the retrospective design, the absence of a control group, the absence of preoperative score values, and the absence of standardised radiological torsion and follow-up imaging, the data do not support any statement on efficacy, on prevention of degenerative change, or on superiority over alternative approaches. These results describe the long-term functional status of a clinically documented cohort.
Abstract:The additional qualifications "Special Orthopaedic Surgery" and "Special Trauma Surgery" are well-established and recognised credentials for specialised care within the field of orthopaedics and trauma surgery. However, given the increasing prevalence of subspecialised care structures, the question arises as to whether the content and requirements of these additional qualifications remain up to date and relevant to clinical practice.The aim of this study was to conduct a systematic analysis of the content and requirements based on the Model Training Regulations (MWBO) of the German Medical Association (BÄK) from 2003 and 2018, as well as the current training regulations (WBO) of all regional medical chambers (LÄK). The number and types of required surgical procedures were examined, along with their distribution across subspecialised areas such as endoprosthetics, spine surgery, shoulder and elbow surgery, and foot and ankle surgery.The analysis reveals a general reduction in the total number of required surgical procedures in both additional qualifications and considerable harmonisation of requirements across regional chambers. In the "Special Orthopaedic Surgery" qualification, up to 49% of procedures involve endoprosthetics, particularly of the lower extremity. In contrast, subspecialised fields such as shoulder and elbow or foot and ankle surgery are underrepresented, despite their growing importance in clinical practice. Furthermore, modern minimally invasive techniques such as arthroscopy are still scarcely addressed.To address the gap between training content and the realities of clinical care-and to ensure high-quality training and long-term healthcare provision-reform of the current training regulations is needed. The Introduction of defined subspecialty tracks, such as shoulder and elbow surgery or foot and ankle surgery, could offer more differentiated and practice-oriented training, and help to ensure high-quality patient care in the future.
Die Beckenverletzungen nehmen über die letzten Jahrzehnte an Häufigkeit zu, sei es durch Hochrasanztraumata oder Bagatelltraumata bei geriatrischen Patienten. Die Therapie reicht von konservativen Maßnahmen bis hin zu operativen Eingriffen. Mit dem Einsatz minimalinvasiver operativer Verfahren nimmt auch die Bedeutung navigierter Beckenchirurgie zu.In dem dargestellten Fall wird eine vordere und hintere Beckenringfraktur mittels O-Arm operativ versorgt. Die Navigation hilft bei komplexer Anatomie und erleichtert die intraoperative Überprüfung der regelrechten Implantatlage, wovon vor allem weniger erfahrene Teams profitieren können. Durch erhöhte Präzision wird die Revisionsrate geringer. Allerdings bedarf es am Anfang einer längeren Operationsdauer und guten interdisziplinären Schulung sowie besonderer Abstimmung mit dem Operations- und Anästhesiepersonal.Das vorgelegte Video demonstriert dabei Schritt für Schritt unser Vorgehen bei der navigierten Schraubenosteosynthese einer Beckenringfraktur.
Objective:The posterior malleolar fragment (PMF) in ankle fractures can be fixed with closed reduction and percutaneous fixation with an anteroposterior screw (Closed Reduction Internal Fixation - CRIF), or with open reduction using a posterior approach and buttress plating (Open Reduction Internal Fixation - ORIF). The objective of this study was to compare these two techniques with respect to postoperative complications and patient-reported outcome measures (PROMs). Materials and Methods:In this retrospective study, data were analysed from 106 consecutive ankle fracture cases involving the PMF that were operated between 2021 and 2022 in a single institution. The PMF was managed either via CRIF (n = 43) or via ORIF (n = 63). A comprehensive analysis was conducted, encompassing patient-, fracture-specific characteristics, and treatment modalities.A minimum follow-up period of three months was deemed necessary in order to ascertain the complication rate, which was available for a total of 65 patients. The documented complications included superficial wound healing impairment without surgical revision, deep wound healing impairment necessitating surgical revision, iatrogenic nerve injury, delayed bone union, and revision surgery.In the second part of the study, patients were contacted for a follow-up assessment using the Foot and Ankle Outcome Score (FAOS), the Foot and Ankle Ability Measure (FAAM) and a numerical rating scale for pain (NRS). Thirty-nine patients participated. Results:Analyses revealed significant disparities in the distribution of Bartoníček fracture types between the ORIF and CRIF groups: type II was more prevalent, and types III and IV less common, in the CRIF group (n = 43) than in the ORIF group (n = 63; p = 0.03). The PMFs in the ORIF group were found to be significantly larger (p = 0.006), and the mean surgical time was significantly prolonged in comparison to the CRIF group (p < 0.0001). The placement of a positioning screw was observed to be significantly more prevalent in the CRIF group than in the ORIF group (18 cases [42%] vs. 10 cases [16%], p = 0.003).Following a median follow-up period of eight months (range 3-37 months), the complication rate was found to be higher in the ORIF group (37%) than in the CRIF group (18%), although this difference was not statistically significant (p = 0.116).After a median follow-up period of 21 (14-36) months, the CRIF group patients showed significantly better results in the FAOS subscales activities of daily living and quality of life compared to the patients in the ORIF group (p = 0.049 and p = 0.045, respectively). Furthermore, the self-assessed ankle function compared to the status prior to the fracture, in the sports category of the FAAM, was better in the CRIF than in the ORIF group (p = 0.029).No significant differences were identified in FAOS total score or NRS between the two groups (p = 0.107 and p = 0.236, respectively). Conclusion:ORIF of the PMF reduces the likelihood of additional syndesmotic stabilisation in comparison with CRIF; however, it is associated with increased surgical time while maintaining similar complication rates.
Background:In hemiplegic patients, joint cartilage alterations may arise from impaired balance reactions, decreased selective motor control, abnormal muscle tone, or reduced weight shifting toward the affected limb. Objective:This study aimed to investigate the thickness of talar, femoral, and metacarpal cartilage on the paretic and nonparetic sides in hemiplegic patients and to compare these findings with those of healthy controls. Methods:Thirty-one hemiplegic patients and 31 age and sex-matched healthy individuals participated. The thickness of talar, femoral, 2nd metacarpal, and 3rd metacarpal cartilage was measured using an ultrasound device equipped with a linear probe. Measurements were performed by the same experienced examiner to ensure reliability. Results:Talar (p = 0.012, r = 0.453) and femoral (p = 0.016, r = 0.431) cartilage were significantly thicker on the paretic side compared with the nonparetic side, while no differences were found in 2nd and 3rd metacarpal cartilage. Compared with controls, talar (p = 0.018, r = 0.299) and femoral (p = 0.036, r = 0.266) cartilage on the paretic side was thicker, whereas the nonparetic side showed no significant difference (p > 0.05). Conclusions:The increased talar and femoral cartilage thickness on the paretic side could potentially be consistent with cartilage oedema or other structural changes; however, ultrasonography alone cannot differentiate between structural thickening, increased water content, subclinical synovitis, or methodological artefacts. Several alternative mechanisms may also contribute to the observed findings, including altered joint alignment, muscular imbalance, and spasticity-related loading changes secondary to hemiplegia. These findings warrant further investigation with longitudinal and multimodal imaging studies.
Abstract:Chronic osteomyelitis remains a significant challenge in orthopaedic and trauma surgery, despite substantial advancements in surgical techniques, antimicrobial therapy, and microbiological diagnostics. The progression from acute to chronic infection is characterised by the formation of bacterial biofilms, which result in profoundly reduced antibiotic susceptibility and pathogen persistence. The Cierny-Mader classification provides a critical clinical framework, by integrating the anatomical extent of the infection with the host's physiological condition. This review summarises current understanding of the pathophysiology of osteomyelitis and delineates stage-appropriate surgical strategies, including radical debridement, dead-space management with local antibiotic carriers, soft-tissue reconstruction, and subsequent bone reconstruction. Furthermore, recent developments in single-stage surgical approaches, shortened systemic antibiotic therapy, and the necessity of interdisciplinary treatment concepts are discussed. A comprehensive understanding of the mechanisms underlying biofilm-associated infection and the implementation of evidence-based, classification-guided treatment protocols are essential for achieving definitive infection control and optimal functional outcomes.
Injuries to the lateral ankle ligaments are among the most common sports injuries in both professional athletes and the general population. Adequate management with consequent bracing after excluding relevant concomitant injuries, and functional aftertreatment, including balance and proprioceptive training, are crucial in preventing chronic lateral ankle instability (CLAI). It is estimated that CLAI develops in approximately 25% of patients following an ankle sprain. The condition is divided into mechanical and functional instability. Diagnosis is primarily clinical, but imaging such as X-rays and magnetic resonance imaging can be very useful in detecting additional pathologies. Most patients improve with non-operative treatment. When this fails, surgery is indicated. Surgical treatment of CLAI is divided into direct ligament repair and indirect reconstruction. Extra-anatomical tenodesis is generally not indicated. Currently, the gold standard is ligament repair with the Broström-Gould technique, with excellent results. Early rehabilitation, including balance and proprioceptive training, plays a pivotal role in regaining postural stability in both acute and chronic lateral ankle instability.
