BACKGROUND:Age-related varus remodeling of the proximal femur is well recognized, but its anatomical center of rotation remains unclear. Varus proximal femoral morphology plays a relevant role in fracture patterns, implant positioning, and surgical exposure in geriatric trauma surgery. We investigated whether correlations between the caput-collum-diaphyseal angle (CCD) and trochanteric rotation/offset parameters indicate a subtrochanteric origin of femoral varisation. METHODS:100 CT angiographies of the pelvis-leg axis from patients of different ages were analyzed. CCD and the critical trochanter angle (CTA) were assessed in their conventional and modified forms (mCCD/mCTA). Additional parameters included greater (OGT/OGTI) and lesser trochanter offsets (OST/OSTI), femoral antetorsion, and trochanteric anteversion/retroversion. Bone quality was classified according to Dorr. RESULTS:mCCD showed a significant negative correlation with age, confirming increasing varus alignment in older individuals. CTA and mCTA positively correlated significantly with both CCD and mCCD (CTA/CCD: p = 0.005 and CTA/mCCD p < 0.001; mCTA: with both CCD & mCCD p < 0.001), indicating that increased medial trochanteric overhang is strongly associated with varus morphology. OGT and OGTI demonstrated strong positive correlations with CCD and mCCD (OGT: with both p < 0.001, OGTI: with both p = 0.001), whereas OST and OSTI correlated negatively with CCD (p = 0.032 and p = 0.02), reflecting a decrease in greater trochanter offset and an increase in lesser trochanter offset with progressive varisation. Posterior trochanteric orientation (PTO) of the greater trochanter correlated positively with CCD/mCCD, indicating reduced retroversion in varus hips. In contrast, femoral neck anteversion and anterior trochanteric anteversion showed no significant correlation with CCD parameters (p = 0.889 and p = 0.125). Lower CCD values were significantly associated with more osteoporotic Dorr types (Kendall's Tau: -0.212 for CCD, p = 0.008; -0.197 for mCCD, p = 0.014). CONCLUSION:Correlation patterns suggest that age-dependent varisation occurs predominantly in the subtrochanteric region. This morphology may complicate exposure and stem alignment in total hip arthroplasty in varus hips and should influence implant selection, stem design and fracture-related implant strategies in elderly patients.

Background Diagnosis of elbow instability in clinical practice commonly relies on manual stress testing by the physician with or without combination of fluoroscopy or ultrasound, which may result in variable force application and subjective interpretation. A standardized method for applying controlled mechanical loading during dynamic imaging may improve reproducibility. Objective The objective of this study was to develop and perform initial cadaveric feasibility testing of a CT-compatible diagnostic device for device-guided assessment of elbow instability with simultaneous force and positional measurement. Design Technical development study with initial cadaveric feasibility testing. Methods Building upon the initial prototype the present paper, describes the development of MELBO the follow-up prototype with adjusted kinematics and improved stability, the validation of the force sensor is addressed, and the first cadaver test results are presented. Results The MELBO diagnostic tool enabled a controlled device-guided elbow motion during 4D-CT acquisition and allowed simultaneous recording of force and positional data. The acquired dynamic CT datasets were suitable for qualitative assessment of elbow joint stability. No relevant device-related imaging artifacts were observed. Conclusion The present study demonstrates the technical feasibility of device-guided simultaneous force and positional measurement during 4D-CT using the MELBO diagnostic tool. These findings provide the basis for further cadaveric studies and future clinical investigations aimed at quantitative assessment of elbow instability under standardized loading conditions.

BackgroundAlthough finger joint capsulitis has been described among the most frequent injuries in climbers, no clinical studies on treatment strategies and outcomes are available.Study designProspective case series study.MethodsBetween 2015 and 2018 we prospectively treated 50 patients (38 male, 12 female) with a total number of 69 independent finger joint capsulitis according to a clinic specific treatment regimen and evaluated the outcome retrospectively. Therapy consisted of either conservative management, steroid injections, radiosynoviorthesis or a combination depending on the treatment regimen, prior therapy and timeline of symptoms. Outcomes were assessed using visual analogue scale (VAS), Buck-Gramcko score and a climbing specific outcome score with secondary patient recall.ResultsThe proximal interphalangeal joint of the middle finger was the most commonly affected joint, and there was no correlation with osteoarthritis. All climbers returned to sport within 12 months. The majority were able to maintain their level of performance after injury and the difference in climbing level before and after injury was not statistically significant (p = 0.22). The total time spent climbing was significantly less after the injury than before the injury (p < 0.001). The Buck-Gramcko score showed excellent results. The overall functional outcome was good to very good with a mean score of 1.6 ± 0.7, as was the climbing specific score of 1.7 ± 0.9. Pain was significantly less after treatment than before (p < 0.001).ConclusionGood to very good functional and sport-specific outcomes were seen with the stage-specific treatment regimen presented, allowing all patients studied to resume climbing. A better understanding of the underlying pathogenesis is essential in order to better assess long-term progress.

Der Klettersport ist eine Sportart, die bis ins hohe Alter ausgeübt werden kann. In Studien hat sich gezeigt, dass sie gesundheitsfördernd und verletzungsarm ist. Dennoch kommt es auch beim Klettern regelmäßig zu akuten und chronischen Verletzungen, insbesondere im Bereich der Hände. Am häufigsten treten Ringbandrupturen der Finger, Kapselentzündungen der kleinen Fingergelenke (Kapsulitis) sowie Tenosynovitiden der Beugesehnen auf. Zudem führt langjähriges Klettern im hohen Schwierigkeitsbereich zu physiologischen Anpassungsvorgängen aber auch zu vermehrten degenerativen Veränderungen im Bereich der Finger. Durch eine korrekte Diagnose und Therapie der o.g. Pathologien lässt sich bei den meisten Patienten die Sportfähigkeit dennoch auf einem hohen Niveau erhalten.

BACKGROUND:Bouldering is known for a high risk of hamate injuries. Over 75 % of sport climbers have signs of upper extremity overuse injuries. Training overload corresponds with bone edema and was linked to fractures of the hamate. To date, no study has addressed the pathomechanism of hamate fracture in climbing. The aim of this study was to investigate the stability of the hamate in a biomechanical setup under the tension of the flexor tendons. METHODS:20 fresh-frozen, unfixed human forearms were used for two test series. The test stand consisted of an modified isokinet. Tension was applied by a motor. The specimens were prepared and positioned in ulnar deviation for the first test series. Additionally, the flexor tendons of the specimens were replaced by a steel cable in the anatomical course for the second series. FINDINGS:In the first series, no fracture occurred at the hamate. Causes for termination of these measurements were tendon rupture and failure of the suture in majority of the cases. In the second setup, tension was applied to the cable with an average maximum force of 1029.4 N [105 kg]. Fracture of the hamate occurred in two out of ten cases. The mean force measured in those cases was 1008.30 N [102.8 kg]. INTERPRETATION:Our results shows that it is possible for flexor tendon's tensile load to cause hamate fracture. It must be considered in patients with ulnar localized pain in the wrist, especially with a suitable sports history. Its quick diagnosis allows further therapy and rehabilitation to be initiated.

Background: Torsional malalignment of the femur and/or tibia is associated with patellar maltracking, and torsional osteotomies have shown to improve clinical symptoms. In patients with severe torsional malalignment, a double-level torsional osteotomy may be necessary. Indications: Symptomatic torsional malalignment leading to patellofemoral maltracking associated with anterior knee pain and/or patellofemoral instability. Technique Description: A double-level torsional osteotomy correcting both increased internal femoral torsion and increased external tibial torsion, is described. Meticulous preoperative deformity analysis and planning of the osteotomy is mandatory. An arthroscopy of the knee is performed first to evaluate the patellofemoral joint and patellar tracking. Tibial torsional correction is performed by a lateral approach. A biplanar osteotomy is performed, and the amount of torsional correction is controlled by 2 Schanz screws. Osteosynthesis can be done via a bended 5-hole DC-Plate or an angle-stable plate. The femoral osteotomy is performed by a medial approach. A uniplanar osteotomy is performed perpendicular to the mechanical axis of the femur. The amount of torsional correction is controlled by 2 Schanz screws. Osteosynthesis is achieved by an angle-stable plate. Results: Double-level torsional osteotomy has been shown to be an effective treatment for patients with patellar dislocation or subluxation associated with severe torsional malalignment. In a series of 18 patients, double-level osteotomy led to improved patellofemoral stability, decreased pain, and increases subjective outcome scores. Discussion/Conclusion: In patients with patellofemoral problems caused by a combined increased tibial external torsion and increased femoral internal torsion, a double-level torsional osteotomy is able to correct torsional angles to normal. Available clinical data on this procedure are promising. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Ein knöchernes Genu recurvatum tritt klinisch durch eine Überstreckbarkeit des Kniegelenks in Erscheinung. Neben den Problemen durch die Hyperextension kann es hierdurch langfristig außerdem zu einer Insuffizienz des hinteren Kreuzbandes (HKB) kommen. Kausale Therapie dieser Tibiakopf-Extensions-Deformität stellt eine Slope erhöhende Tibiakopf-Osteotomie dar. Hierzu gibt es bisher kaum Publikationen zu klinischen Ergebnissen, insbesondere zur reinen Slopekorrektur ohne Veränderung der Frontalachse. Im Folgenden wird die Technik der transtuberositären ventral öffnenden Tibiakopf-Flexions-Osteotomie zur Erhöhung des tibialen Slope gezeigt (mit Ablösen und Bioplating der Tuberositas tibiae) (transtuberositary anterior opening wedge high tibial osteotomy, TT-AOW HTO). Nach vorgeschalteter Arthroskopie erfolgen nach der Osteotomie von ventral die Interposition eines autologen Beckenkammspans und die Osteosynthese mit zwei winkelstabilen Platten von medial bzw. anteromedial.

Patellar dislocations in flexion, which occurs permanently with every movement, is the most serious manifestation of patellofemoral malalignment. Surgical approaches to correct this problem have been mostly unsuccessful. In a new therapeutic approach, the concave posterior surface of the patella, which slides on the hypoplastic lateral condyle as if guided by splints, is seen as the main pathology. The appropriate surgical strategy is trochleoplasty, combined with closed wedge patellar osteotomy, tuberosity medialisation, procedure for lengthening lateral retinaculum and MPFL plasty with the quadriceps tendon. In the case of a 13-year-old female patient presented here, this procedure leads to permanent stability in a symptom-free knee joint on both sides.

Rationale and Objectives: There are currently no studies investigating the in vivo stiffness of the most commonly used autografts for anterior cruciate ligament reconstruction (ACLR) using Shear wave elastography (SWE). We hypothesize that there are differences regarding the elastic properties between the three tendons commonly used for ACLR and that they are influenced by patient-related factors. Materials and Methods: 80 healthy subjects (25 females, 55 males, age: 25.33 +/- 4.76 years, BMI: 23.76 +/- 3.14 kg/m(2), 40 semiprofessional athletes, athlete group [AG], age: 25.51 [19-29]; 40 healthy controls, control group [CG], age: 25.50 [20-29]) were recruited as participants. In addition to patient reported outcome scores, every participant underwent a standardized multimodal ultrasound protocol consisting of B-mode-ultrasound (B-US), Color Doppler-ultrasound (CD-US) and a SWE examination of the bilateral quadriceps tendon (QT), patellar tendon (PT) and semitendinosus tendon (ST). Results: The highest shear wave velocity (SWV) were observed in ST (4.88 (4.35-5.52) m/s, ST vs QT, p = 0.005; ST vs PT, p < 0.001) followed by QT (4.61 (4.13-5.26) m/s, QT vs PT, p < 0.001) and PT (3.73 (3.30-4.68) m/s). Median QT, PT and ST stiffness was significantly higher in AG compared to CG. Male subjects tend to have stiffer QT and PT than female subjects. Positive correlation with SWV was obtained for age and activity level. Conclusion: There are significant differences regarding in vivo tendon stiffness between the most frequently used autograft tendon options for ACLR. The quantitative information obtained by SWE could be of particular interest for graft choice for ACLR. (c) 2024 The Association of University Radiologists. Published by Elsevier Inc. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

ZusammenfassungEin knöchernes Genu recurvatum tritt klinisch durch eine Überstreckbarkeit des Kniegelenks in Erscheinung. Neben den Problemen durch die Hyperextension kann es hierdurch langfristig außerdem zu einer Insuffizienz des hinteren Kreuzbandes (HKB) kommen. Kausale Therapie dieser Tibiakopfextensionsdeformität stellt eine Slope-erhöhende Tibiakopfosteotomie dar. Hierbei gibt es bisher nur wenige Publikationen zu klinischen Ergebnissen, insbesondere zur reinen Slope-Korrektur ohne Veränderung der Frontalachse. Im Folgenden wird die Technik der transtuberositären ventral öffnenden Tibiakopf-Flexions-Osteotomie (Transtuberositary Anterior Opening Wedge High Tibial Osteotomy, TT-AOW HTO) zur Erhöhung des tibialen Slope gezeigt (mit Ablösen und „Bioplating“ der Tuberositas tibiae). Nach vorgeschalteter Arthroskopie erfolgt nach der Osteotomie von ventral die Interposition eines autologen Beckenkammspans und die Osteosynthese mit 2 winkelstabilen Platten von medial und anteromedial.

Patellar dislocations in flexion, which occurs permanently with every movement, is the most serious manifestation of patellofemoral malalignment. Surgical approaches to correct this problem have been mostly unsuccessful. In a new therapeutic approach, the concave posterior surface of the patella, which slides on the hypoplastic lateral condyle as if guided by splints, is seen as the main pathology. The appropriate surgical strategy is trochleoplasty, combined with closed wedge patellar osteotomy, tuberosity medialisation, procedure for lengthening lateral retinaculum and MPFL plasty with the quadriceps tendon. In the case of a 13-year-old female patient presented here, this procedure leads to permanent stability in a symptom-free knee joint on both sides.

Introduction Traumatic shoulder dislocations rank among the most common shoulder injuries in climbers, with rising numbers over the last years. The objective of this study was to analyze the outcome following traumatic first-time shoulder dislocation and subsequent surgical treatment in this population. Methods In a retrospective study, climbers who experienced a traumatic shoulder dislocation were treated with an arthroscopic repair of the labrum-ligament complex (LLC). The functional outcome was assessed with a standardized questionnaire and clinical examination, including the Constant Murley and Single Assessment Numeric Evaluation scores. The sport-specific outcome was analyzed using the Union Internationale des Associations d’Alpinisme (UIAA) scale of difficulty and a sport-specific outcome score. Results The functional and sport-specific outcome for 27 climbers (20 men; 7 women; 3 with bilateral injuries; age, 34±11 [17–61] y; data presented as mean±SD [range]) was assessed 53±29 (12–103) mo after surgery. The postoperative Constant Murley score was 95±8 (67–100) points. At follow-up, 93% (n=25) of patients had started climbing again. Twenty-one climbers (78%) reached a climbing level within the range of ±0.33 UIAA grades of their initial capability or even exceeded their preinjury grade. Only 7% (n=2) of the patients had a recurrent shoulder dislocation, leading to a secondary surgery, and, therefore, required ongoing postoperative treatment at the time of follow-up. Conclusions Arthroscopic repair of the LLC following first-time traumatic shoulder dislocation in climbers shows a good outcome and a low recurrence rate. After surgery, most patients are able to regain a high level of rock-climbing ability.

Background: Closed finger flexor tendon pulley injuries occur most frequently in rock climbing but also during other heavy finger strength work or exercises. While single pulley injuries receive a conservative therapy, multiple pulley injuries often require a surgical repair, as otherwise they will lead to contracture and loss of range of motion and functionality. While established surgical techniques, which use bone encircling tendon graft techniques, were found to produce osteonecrosis of the phalanx, our new transosseous technique avoids this problem. Indications: All triple pulley injuries (A2,3,4) (grade-4b injuries) and double pulley injuries (A2,3 or A3,4) (grade-4a injuries) are indicated, if the injury is older than 10 days at the point of therapy start or the flexor tendons bowstringing is either not redressable in the ultrasound or extended. Also, grade-4a injuries are indicated, if a secondary contracture starts to build. Technique Description: Standard palmar-sided incision, followed by debridement of the tendon sheath, pulley flap, and, if applicable, scare tissue in between the flexor tendons and the bone is performed. Wire-guided 3.0-mm drill holes at the base phalanx at the level of the former distal portion of the A2 pulley are completed. Passing of the palmaris longus tendon through the drill hole and interlacing it as a “loop and a half” follows. Distal continuation through lacing the transplant through the remaining rims of the former pulleys and the flexor tendon sheath is then performed. Securing the repair after tendon gliding control to itself is completed. Postsurgically, the splint is immobilized for 2 weeks, followed by the use of a thermoplastic pulley support ring for 4 weeks with active mobilization. Results: No complications occurred during or after the surgery. In few cases, a restricted range of motion in the proximal interphalangeal (PIP) joint of the respective finger of up to 3 to 5 grade occurred. One patient, who had a presurgical PIP extension deficit of 30°, which was released during the surgery, developed over time again a 20° extension deficit. The functional outcome score ranged between good and excellent, with one case being only satisfactory. The sport-specific outcome score was either good or excellent for all patients, with one patient with contracture where it was satisfactory. No osteonecrosis of the phalanx was recorded. Discussion: For multiple pulley ruptures, various surgical techniques are described. We favored a modified “loop and a half” technique with a distal continuation to the A3 pulley. This combines the advantages of the “loop and a half” technique, as the strongest, and the Weilby repair, as the most functional repair. We recently noticed some cases with osseous necrosis of the phalanx following this repair, likely due to the high pressure of the circulation of the tendon graft onto the bone and its blood vessels. Therefore, we have modified our procedure into a transosseous repair, which is presented in this article. This approach was first evaluated in a cadaver study to exclude a potential risk of osseous failure (fracture) during stress caused by the drill hole. After ruling out this risk, the transosseous technique became our standard approach, as it combines the advantages of the “loop and a half” technique with those of the Weilby repair and decreases the pressure onto the dorsal cortex of the fingers base phalanx and thus the risk of osteonecrosis.